Disease
Pathophysiology
Acute calculous cholecystitis
Obstruction of cystic duct by gallstone
Choledocholithiasis
Common bile duct (CBD) obstruction by gallstone
Gallstone pancreatitis
Transient obstruction of the distal CBD (and pancreatic duct)
Cholangitis
Ascending bacterial infection of the biliary system associated with CBD obstruction
Viral hepatitis
Viral infection of the liver, can be acute or chronic
Mirizzi’s syndrome
Large stone lodged in the neck of the gallbladder causing external compression of the common hepatic duct
Pyogenic (bacterial) liver abscess
Hematogenous infection (e.g., endocarditis, IV drugs), or local spread from biliary disease
Amoebic liver abscess
Entamoeba histolytica enters portal system from colon via ulceration
Does the Patient Manifest Systemic Inflammatory Response Syndrome (SIRS)? What Is the Definition of SIRS?
Yes she does. SIRS may be diagnosed when at least two of the following criteria are met:
T > 100.4 °F or < 96.8 °F
HR > 90 bpm
Respiratory rate > 20 breaths per minute or PaCO2 < 32 mmHg or patient is mechanically ventilated
WBC > 12 × 103/μL or 4 × 103/μL or > 10 % band forms
It is important to note that SIRS may or may not be due to infection. If a patient meets the criteria for SIRS and has an identifiable source of infection (e.g., pneumonia, cholangitis), the patient has sepsis.
What Is the Diagnosis for This Patient?
The most likely diagnosis in a patient with a 1-day history of RUQ pain worsened with greasy foods, nausea, altered mental status, jaundice, and fever is acute cholangitis secondary to gallstone impaction. Additionally, she has leukocytosis, hypotension, elevated bilirubin, and liver function tests, all of which are consistent with the diagnosis.
What Are the Diagnostic Criteria for Cholangitis?
The Tokyo guidelines have been proposed as diagnostic criteria for acute cholangitis. Patients should have evidence of systemic inflammation (fever and/or leukocytosis), cholestasis (jaundice and/or abnormal liver enzymes), and biliary obstruction (dilated bile ducts on ultrasound).
History and Physical
What Are the Causes of Obstructive Jaundice That Lead to Cholangitis?
Gallstones are the most common cause. Other causes of obstruction include bile duct strictures, parasites (such as Ascaris lumbricoides and Chinese liver fluke, Clonorchis sinensis), instrumentation of the biliary system (such as during ERCP), and indwelling biliary stents.
Would You Expect Pale Stools?
Pale or acholic stools are a result of prolonged biliary obstruction, so this would not be expected in patients with gallstone cholangitis.
At What Level of Bilirubin Will Jaundice First Be Visible?
Jaundice will be visible at total bilirubin level > 2.5 mg/dL. Normal total bilirubin level is up to 1.0 mg/dL.
Where Do You Look for Jaundice?
Jaundice will manifest first in the sclerae of the eyes and under the tongue, as blood vessels here are more superficial. It will then descend down toward the chest, abdomen, and legs.
What Is Charcot’s Triad?
Charcot’s triad consists of fever, right upper quadrant pain, and jaundice. This cluster of symptoms is classically associated with cholangitis.
What Percent of Patients with Cholangitis Have All 3 of the Triad?
This presentation is found in only about 40–50 % of patients with cholangitis. Thus in actuality Charcot’s triad is not very sensitive. Jaundice is not always clinically obvious.
What Is Reynold’s Pentad? What Percent of Patients with Cholangitis Have All Components?
Reynold’s pentad implies cholangitis with septic shock. It includes Charcot’s triad plus hypotension and mental status changes. It is present in the minority of patients with cholangitis (5 %). An altered mental status is indicative of severe disease and associated with a poor prognosis.
